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DA . Fz �- AN )OAQUIN COUNTY - EHD LOG NUMBER <br /> VL11 3 <br /> d �(� RONMENTAL HEALTH DEPARTMENT <br /> n � (A 186st Hazelton Avenue, Stockton, CA 95205-6232 <br /> JUN 7 6 2��'F� Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd <br /> E m� <br /> .e_veerrae 9314 PUBLIC RECORDS RELEASE APPLICATION <br /> malrK � ���'�'1 BUSINESS/AGENCY: -UK5 <br /> ADDRESS: IaI47-O f(16�fVix Pr-) Sf� )gyp CITY/STATE2EP:Clar'y7-, 1-f' ;1 MP rp7-7(o <br /> PHONE (1): l-q,Z,p-7i?.-7`I PHONE(2): (' P01��(�'-�G7b?FAX OR E-1VIAIL: t I0I SZC�'2,C;O-j <br /> Please allow 10 business days from date of application submittal far the records to be available. <br /> Staff will contact you to arrange an appointment date and time to review the requested records. <br /> ❑ CHECK BOX TO EXPEDITE REQUEST-$130 FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT _<•P� � DATE <br /> 11. List up to ten addresses in the space below. Select the type(s) of files from the list below by checking the appropriate <br /> box(es). At least one file type MUST be selected. Fax to(203)464-0138 or mail to the address indicated above. Address <br /> ranges will not be accepted.Appl1cations received after 3:00 pm Will be processed the next business day. <br /> 2. For assistance in identifying the nature and content of EHD records, please Contact EHD at the number noted above. <br /> 3. The EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately ten (10) <br /> days after receipt of application. The files will ba held for a maximum of five business days for review. Appointments <br /> should be scheduled accordingly. <br /> 4. Any file not returned in the same condition as released Will be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviews by the same applicant may require a $130 deposit prior to review. <br /> WELL AND SEPTIC PERIMT RECORDS ARE AVAILABLE FOR REVIEW: MONDAY-FRIDAY 8:00 AM-5:OOPM(EXCLUDING HOLIDAYS) <br /> Electronic Information: ❑ List ❑ Map- Description: <br /> Specific Date Range of Information Requested: From 2x10 to SOI 110 <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT FILE ADDRESSFILES EHD USE <br /> ONLY <br /> UNDERGROUND TANK(UST) Street# Street Name City <br /> /CLEANUP SITE(LOP) (��y�� J�(�l/n COT f / /��) ❑CONSUMER <br /> i /OTHER CLEANUP SITE(NON `+{'- / rnV /� <br /> .HAZARDOUS WASTE 1 <br /> DAIRY <br /> ©/TIERED PERMITTED FACILITY 2 <br /> ABOVEGROUND TANK <br /> BUST (MONITORING/REMOVAL) �PWS <br /> dHAZARDCUS MATERIALS , <br /> �SPIUJRELEASE RESPONSE WATER QUALITY <br /> WASTE FACILITY/VEHICLE 4 <br /> ❑FOOD FACILITY / <br /> ❑POOL/$PA $ITE MITIGATION <br /> ❑DAIRY 5 V <br /> ❑LAND USE APPLICATION SITES <br /> ❑SEPTIC PUMPER TRUCK/ 6 1:1 HOUSING <br /> 54ARD/CHEMICAL TOILETS <br /> WASTEWATER TREATMENT PLANT j1CUPA <br /> ❑HOUSING ABATEMENT 7 <br /> ❑MOTEUHOTEL <br /> ❑CHICKEN RANCH/DOG KENNEL �CUPA-HAZ-MAT <br /> 8 <br /> ❑MEDICAL WASTE FACILITY <br /> ❑TATTOO/BODY PIERCING <br /> WASTE TIRE - SOUO WASTE <br /> 9 <br /> ❑COMPLAINT <br /> ❑OTHER(PLEASE SPECIFY): - F)ACCOUNTING <br /> TD <br /> 1 -BOXED AREA-EHD USE ONLY-' <br /> ✓l Ul n /. <br /> i <br /> ❑ Records provided by Staff-PPR Complete. staff Name: <br /> EHD 48-06 <br />